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CMS (Centers for Medicare and Medicaid Services) requires their administrative contractors (MACs) to issue Local Coverage Determinations (LCD) when they have local guidelines directing how to bill for certain services. LCDs can designate diagnosis codes felt to justify medical necessity for the service, establish billing guidelines, and/or specify limitations on frequency and patient eligibility. The MAC Part B contractor for South Carolina, Palmetto GBA, adjudicates claims for HPV designated as high-risk types, or when both low- and high-risk types are performed in a single assay, (CPT code 87624) in accordance with LCD #L31747. It is important to note, that some commercial plans will follow CMS claims processing and payment guidelines.
This LCD includes a limited list of covered diagnosis codes deemed medically necessary by the contractor for reimbursement of this service. Please note the degree of specificity needed in documenting a final diagnosis.
• 622.10 Dysplasia of cervix, unspecified
• 622.11 Mild dysplasia of cervix
• 622.12 Moderate dysplasia of cervix
• 795.00 Abnormal glandular Papanicolaou smear of cervix
• 795.01 Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US)
• 795.03 Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
As proper code assignment is based on the final diagnosis on the case, APS Medical Billing has processes in place to review the report for documentation that will appropriately allow the coding of a diagnosis that is on the approved list. Feedback is provided to practices whose documentation and/or ICD-9 codes do not meet the guidelines of this LCD.